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Nails, ears and other painful exams: Using analgesia and sedation to make it better for the patient (Proceedings)

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Aug 01, 2009

Currently available sedative analgesic agents have opened up a wonderful world of opportunity to practice with intelligent compassion: to work smarter, not harder when managing patients that resent a variety of necessary procedures.

This session will focus on strategies that combine opioids, sedative/tranquilizers, and dissociative agents to provide predictable chemical restraint with properties that include rapid onset, reversibility, and minimal potential for clinically significant adverse effects.

Overview of presentation:

Veterinary medicine often has a tough side to it; brute-a-caine is the general term for gathering enough people to overcome any physical resistance by the patient to force their compliance. It seems expedient to just get the job done but the consequences of these events are often inadequately considered.

With heavy physical restraint, there is high-level stress for both the patient and the staff, there is every expectation that the patient will generate a substantial negative association with the practice, and there is predictable risk of physical harm, including death, to the patient as well as the risk of physical harm to the staff. As an extension of this overall negative association, when the patient has a negative association with the practice, the client is likely to avoid trips to the practice for routine care, impacting the business of veterinary medicine. What seems easiest in the short term has ongoing life-long consequences.

The first step in the effective utilization of procedural sedation is to recognize which patients require it. We try to build the most positive relationship that we possibly can from the earliest patient visits. Freeze dried liver treats are in the canine rooms and a variety of strained meat baby foods are in the feline exam room. Every attempt is made to distract the patient from the unpleasantries of their initial vaccinations.

When blood draws and other more challenging needs arise, we conduct those away from the DVM in a room apart from the outpatient area, making an attempt to diffuse negative associations. If the patient becomes agitated by a procedure we consider abandoning the event that day, postponing it until a future visit. We then set up a series of "Happy Visits" prior to the next stressful event making an attempt to build a more positive bond with both client and patient. This is a more successful sequence when managing canine compared to feline patients.

When all else fails, procedural sedation is woven into the patient's visits. Whenever possible, we avoid trying to gain control of a highly agitated patient preferring to reschedule a patient that has become highly reactive to another day (if their condition allows). To do otherwise risks escalating hostilities and escalating drug requirements.

For the toughest patients, procedural sedation is the only way we can gain enough control to perform even the most basic of all procedures: a physical examination. This reduces the safety of the event as these patients require more aggressive drug combinations while offering the clinician the least understanding of their health status.

Simply put, the timing of the medication administration has a crucial impact to the success of the process. A known difficult patient should be given their sedative IM medication combination as a soon as they walk through the door of the practice. If they are allowed to become increasingly agitated, their medication strategy is less likely to be effective delaying the patient procedure and forcing the need for additional drugs.

For cats, we prefer to have the patient transported to the practice in a simple 2-part plastic carrier that has an easily removed top. The patient is ushered into an exam room that has a calming pheromone diffuser in place. The top of the carrier is removed and the patient is quickly covered with a towel that has also been sprayed with a calming pheromone. The staff member gently but firmly presses the patient against the floor of the carrier while a second staff member lifts the towel off of the lower lumbar area allowing a quick IM injection in the lumbar epaxial musculature using a 25 g or 27 g needle.

The patients head is uncovered and the staff exits the room leaving instructions with the owner to open the door when the patient begins to act sleepy. Subdued lighting may help accelerate the medication's effects. The staff member returns in 10 minutes if the owner hasn't already come to the door. If the patient escapes into the room we use a clam-shell cat collection device to safely gather up the patient and easily allow for the IM injection while restrained in the mesh. We can usually gain control of even the toughest cats using this method. What varies is the choice of drugs for these patients; usually ketamine is required to securely gain control of these agitated tough cats.